Common Rheumatology Issues in Hospital Medicine Lianne Gensler, MD - - PDF document

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Common Rheumatology Issues in Hospital Medicine Lianne Gensler, MD Associate Professor of Clinical Medicine UCSF Division of Rheumatology Disclosure UCB Board Member/Advisory Panels 2 1 | [footer text here] Outline 71 year old with

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Common Rheumatology Issues in Hospital Medicine

Lianne Gensler, MD Associate Professor of Clinical Medicine UCSF Division of Rheumatology

Disclosure

  • UCB

Board Member/Advisory Panels

2

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Outline

  • 71 year old with a hot knee
  • A 67 year old with Dyspnea & Acute Kidney Injury
  • 28 year old woman with cough, dyspnea and

fever

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Demography is important!

  • Age
  • Younger age – consider SLE,

APS, reactive arthritis & genetic disorders (periodic fever syndromes)

  • Older age – consider ANCA

vasculitis, GCA, crystal arthritis

  • Gender
  • Females – SLE, MCTD, Sjogren’s,

Scleroderma; premenopausal (no gout)

  • Ethnicity
  • African Americans – SLE, Sarcoid;

almost never GCA

  • Turkish – Bechet's disease, FMF
  • Filipino - gout
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The case of the swollen knee

Initial Presentation

  • 71 year old man with HFpEF admitted 3 days prior with CHF exacerbation
  • After 2 days of diuresis, the patient’s dyspnea improved.
  • Started complaining of left knee pain and swelling

Past Medical History HTN, CAD, HFpEF, CKD (stage 3), gout, Psoriatic Arthritis (PsA) Medications Medications: ACEi, Beta blocker, ASA, IL17Ai (monoclonal antibody biologic for PsA)

The case of the swollen knee

Vital Signs

  • BP 155/88 , Pulse: 80 , Temp 98.9oC; O2

sat 94% on RA Constitutional

  • Well-developed and well-nourished
  • In no apparent distress

Cardiac

  • RRR, S4, no murmurs
  • 1+ pitting edema

Musculoskeletal

  • Right Knee swelling and warmth.

Skin

  • No nodules or purpura; no tophi
  • + mild plaque psoriasis and nail dystrophy

Pulmonary

  • Bibasilar crackles, normal resp effort
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How to identify the hot knee

  • Temperature
  • Joints should be cooler than the rest of ext
  • Bulge test
  • Squeeze fluid out of the suprapatellar pouch
  • Medial compartment emptied by pressing

medial aspect of joint

  • Lift hand away
  • Lateral side sharply compressed
  • Ripple seen on the flattened medial surface

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The differential diagnosis of a monoarticular hot joint

Aspiration of Swollen Joint Narrows ddx Crystals (+) Gout

birefringent -

Acute CPPD / Pseudo- gout

birefringent +

Crystals (-) Septic Joint Bacterial

Staph, GC

Atypical

Mycobacteri a, spirochete

Fungal RA Psoriatic Arthritis Reactive Arthritis Trauma

Hemarthrosis, meniscal derangement

Osteoarthritis

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Differential Diagnosis of the swollen joint

  • Rule out infection; look for crystals
  • Septic Joint
  • Immunosuppressed
  • Damaged joint
  • Psoriasis portal of entry
  • Psoriatic Arthritis
  • Holding meds? Is this typical

joint for this patient? Diagnosis of exclusion

  • Gout
  • Psoriasis
  • Diuresis & low dose ASA
  • CKD
  • Acute CPPD (Pseudogout)
  • The knee is a good joint
  • CKD (via

hyperparathyroidism)

The hot joint: Crystals and Pearls

Crystals WBCs/mm3 Pearls Septic joint No >20,000 Early in process, counts can be lower Gout Yes 10,000 - >50,000 Acute CPPD (Pseudogout) Sometimes! 10,000 - >50,000 Lab can miss crystals Rheumatoid Arthritis No 3,000 – 30,000 Not usually acute Spondyloarthritis Reactive Arthritis Psoriatic Arthritis No 15- > 50,000 3,000 – 30,000 Not usually acute Non-inflammatory (Osteoarthritis) No <2000 Not usually warm

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Bacterial Septic Joint

  • Prevalence: in adults presenting with >= 1 acutely swollen

joint estimated 10%

Margaretten ME, Kohlwes J, Moore D, Bent S; JAMA. 2007;297(13):1478.

Sensitivity (95%CI) Specificity (95%CI) Joint pain 85% (78-90) Joint swelling 78% (71-85) Fever 57% (52-62) Night sweats 27% (20-34) Rigors 19%(15-24) Risk factors Age IVDU DM, RA, HIV Joint surgery; prostheses Skin infection

Gout

  • Most common inflammatory arthritis in US
  • 8.3 million adults
  • 2x hospitalization rates
  • Increased economic burden
  • More cardiovascular disease & metabolic syndrome
  • NHANES 2007-8: > 70% CKD ≥ stage2 / HTN

Zhu Y et al. Arth Rheum 2011; 63:3136-41; Lim SY et al. Ann Rheum Dis 2012; 71:1765-70; Kuo CF Nat Rev Rheumatol 2015; 11:649-62; Choi HK et al. Arth Rheum 2007;57:109-15; Zhu Y et al. Am J Med 2012:125(7) 679-87

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What to do with Gout medications in the admitted patient

  • Allopurinol/Febuxostat
  • Do not stop allopurinol unless absolutely indicated
  • Hypersensitivity reaction
  • Colchicine
  • Renal Failure
  • Unexplained myopathy or neuropathy
  • Medicare claims data: higher allopurinol dose protected against incident

renal failure

  • The Health Improvement Network (THIN): incident allopurinol use in incident

gout was not associated with increased HR for CKD ≥ 3

Singh JA Ann Rheum Dis 2017; 76:113-139 Khanna D et al. 2012 Arth Care Res (Hoboken) 64, 1447-61 Vargas-Santos AB et al. Arthritis Rheumatol. 2016; 68 (suppl 10)

Colchicine for Acute Gout

  • Use within 36 hours of an attack
  • 1.2mg followed by 0.6mg 1 hour later followed by 0.6mg 1-

2x/day

  • For attacks during ULT with colchicine prophylaxis, can

consider an additional dose

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A 67 year old with Dyspnea & Acute Kidney Injury

Initial Presentation 67 yo male admitted with fatigue, dyspnea progressive over the last month and AKI Past Medical History Bronchiectasis Atrial Fibrillation Former heavy EtoH ROS Tactile fever, no chills or night sweats + 40lb weight loss and generalized weakness No eye pain or vision change Dyspnea, cough non-productive; no hemoptysis No chest pain No sinus symptoms, abdominal complaints, numbness or weakness No joint pain No rashes Medications Metoprolol Aspirin Social History Vietnam Veteran. Retired from real estate. Housed.

  • Divorced. Former smoker. No illicits. No EtoH

Family History No history of autoimmune disease. Father with CAD/MI at 50 years old. Mother with breast CA

A 67 year old with Dyspnea & Acute Kidney Injury

Vital Signs

  • T 36.8 BP 103/63 P: 90-110 RR 16 Sp02

90% RA Constitutional

  • thin but otherwise well appearing

Cardiac

  • Irregularly irregular. No murmurs
  • No edema

Pulmonary

  • Inspiratory bibasilar crackles

HEENT

  • Poor dentition. No oral ulcers
  • No scleral injection. no cervical adenopathy

Gastrointestinal

  • Soft, NT, no hepatosplenomegaly

Musculoskeletal

  • No synovitis, including no joint tenderness or

swelling Neuro

  • A&O x 3. Motor and sensory exam intact
  • Motor strength 5/5 upper/lower ext

Skin

  • + non blanching macular rash on lower ext. No

nodules

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Labs

Micro: Blood cx: 1 of 2 sets + MSSA HIV negative Hep B and Hep C negative QFT negative (6/2017) IgG 1723 (H) IgA 508 (H) IgM 105 (wnl) C3 101 C4 15 ESR >100 CRP 50

3.2 12.2 455

UA: 11 RBCs, 2 WBC, 100 mg/dl protein, few dysmorphic RBCs UPCR: 1.89 grams

7.6 135 4.7 106 18 56 9.2 4.1

Albumin 3.2 total protein 7.9

23.5

SPEP/IFE: no paraprotein Utox: negative

2.0

ANA sub-serologies (-) +ANCA >1:640, MPO>800 ANA 1:320 speckled

The Phenotype of ANA (SLE) & ANCA diseases (AAV)

SLE (Younger F) AAV (Older M) Skin +++ Photosensitive + Palpable purpura Renal +++ Immune complex GN +++ Pauci-immune GN Pulmonary ++ DAH, Serositis +++ DAH, Pulm nodules WBC +++ Leukopenia, lymphopenia ++ Leukocytosis Platelets ++ ITP, APS ++ Thrombocytosis Hemoglobin +++ ACD, AIHA +++ ACD Joints +++ Small joint polyarthritis + variable ESR/CRP +++ ESR>CRP +++ ESR & CRP C3/4 +++ Often low

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IF: Negative

Pulmonary manifestations of ANCA Associated Vasculitis (AAV)

Nodules

Microscopic Polyangiitis (MPA) Granulomatosis & Polyangiitis (GPA)

DAH

Bronchiectasis Tracheal/ bronchial stenosis

ILD

Mohammad et al. J Rheumatol 2017.

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ANCA Vasculitis

GPA MPA EGPA Sinusitis +++

  • ++

Most common pulmonary Pulmonary nodules DAH Asthma Renal Pauci-immune GN Pauci-immune GN Pauci-immune GN +/- eosinophils Neuro Mononeuritis multiplex Peripheral Neuropathy Mononeuritis multiplex Ocular PUK, scleritis > uveitis

ANCA testing

  • Indirect immunofluorescence assay
  • pattern & titer
  • More sensitive
  • ELISA using purified specific

antigens

  • More specific
  • Proteinase 3 (PR3)
  • Myeloperoxidase (MPO)
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ANCA testing

Vasculitis type Formally known as ANCA + Typical ANCA Fluorescence Myeloperoxidase (MPO) & Anti-Proteinase 3 (PR3) Granulomatosis with Polyangiitis (GPA) Wegner’s Granulomatosis 90% systemic 40% limited C-ANCA PR3 > MPO Microscopic Polyangiitis (MPA)

  • P-ANCA

MPO > PR3 Eosinophilic Granulomatosis with Polyangiitis (EGPA) Churg-Strauss Syndrome 40% MPO > PR3

Other considerations Typical ANCA Fluorescence Myeloperoxidas e (MPO) Anti Proteinase 3 Levamisole C-ANCA

  • ++

IBD P-ANCA

28 year old woman with Lupus presenting with cough, dyspnea and fever

Initial Presentation

  • 1 week ago - developed cough & dyspnea.
  • Past 6 weeks, lupus has been in a mild-moderate

flare, characterized by fatigue, malar rash & increased joint pains

  • Reported fevers to 101.5 & rigors. No night sweats

Past Medical History PMH: Systemic Lupus Erythematosus: ANA+ dsDNA+ low complements, rash, arthritis Medications Hydroxychloroquine Prednisone 15mg per day Methotrexate 15mg per week/daily folate

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28 year old woman with cough, dyspnea and fever

Vital Signs

  • BP 90/55 , Pulse: 110 , RR 20, O2 sat

89% on RA Constitutional

  • Ill appearing, cushingoid
  • In moderate resp distress

Cardiac

  • Tachycardic, regular, no murmurs
  • No edema

Musculoskeletal

  • No synovitis, including no joint tenderness or

swelling, but +joint laxity Skin

  • Malar rash, no nodules or purpura.
  • +Livedo reticularis

Pulmonary

  • Decreased breath sounds right base
  • Crackles at left base

HEENT

  • No scleral injection
  • No oral ulcers
  • Diffuse alopecia

Neuro

  • Alert & oriented. Sensation intact
  • Motor strength 5/5 U/L extremities

Differential Diagnosis

Lupus Flare Infection Drug Fever

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Differential Diagnosis

Lupus Flare Infection Drug Fever Leukopenia Leukocytosis Check drug list Thrombocytopenia Thrombocytosis Low grade fever High fever/rigors/chills Lupus symptoms (current and past) Lupus serology Physical evidence

Work-Up

Lab Tests Procedures WBC Chest X-Ray +/- advanced imaging U/A Anti- dsDNA, complement (C3 +/- C4) Infection work up

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Recommendations

Indications for Empiric Antibiotic Treatment

  • Local findings suggestive of infection
  • Precarious clinical status

Indications for Boosting Prednisone

  • No apparent infection
  • Active lupus